23 Feb 2016 Lisa Margaret DAY · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to discuss alternative hospital conveyance options with the person arranging care View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Lisa Margaret DAY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lisa Margaret Day died from cardiac arrhythmia from hyperkalemia, associated with diabetic ketoacidosis and poorly controlled type I diabetes. An ambulance arrived approximately four and a half hours after first being called, and concerns were raised that the 111 service did not discuss alternative transport with the friend who made the call or explain the grave consequences of vomiting illness in a person with diabetes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to discuss alternative hospital conveyance options with the person arranging care
Wider context from the report “1. When Ms Day’s friend rang the 111 service on her behalf, the possibility of conveying her to hospital by means other than an ambulance was discussed with her and she declined.
However, it was not discussed with her friend who made the call. He would have been much better placed to organise this and, if he had, it would probably have resulted in life saving hospital treatment.
The potentially very grave consequences of a vomiting illness in a person with diabetes were not explained to him.
” Source location Lisa Margaret DAY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the agreed London-wide protocol requiring clinicians to explain ambulance delays and self-transfer risks, involve callers, provide updates, and reiterate worsening instructions.
Verbatim wording from the response “It is acknowledged that this alternative means of conveyance if undertaken in Ms Day’s case may have resulted in life saving hospital treatment and as a result the group representing all London 111 providers have agreed the following amendment to the memorandum of understanding in place between the providers and the London Ambulance Service:” Source location Lisa-Day-Response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the concern about explaining risks and discussing non-ambulance conveyance rests with the London Central and West Unscheduled Care Collaborative and Dr Ladbrooke.
Verbatim wording from the response “I understand that the first concern is a matter for the London Central and West Unscheduled Care Collaborative and that Dr Ladbrooke will be responding.” Source location Lisa-Day-Response2
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24 Dec 2015 CHRISTOPHER JONATHAN HIGGINS · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Lack of an agreed pathway for detained patients requiring assessment and treatment at A & E View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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CHRISTOPHER JONATHAN HIGGINS · Prevention of Future Deaths report
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Report summary
Christopher Jonathan Higgins died on 2 July 2013 after sustaining a head injury when he dived over railings while being taken outside for a cigarette at the Fermoy Unit. The report identified concerns about staff understanding of patient observations, patient transfers involving other services, risk assessment of the environment, and arrangements for detained patients requiring assessment and treatment at A&E.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of an agreed pathway for detained patients requiring assessment and treatment at A & E
Wider context from the report “(4) There is no agreement in place between the NSFT and the Acute Hospital as to the best way to deal with patients subject to detention under the Mental Health Act who require assessment and treatment at A & E , as a result of which Mr Higgins, was required to wait over 2 hours in a busy, public area , having already self-harmed and shown signs of paranoia.
” Source location CHRISTOPHER JONATHAN HIGGINS · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and monitor an agreed acute-care pathway with clinician communication channels and a flowchart for detained mental-health patients requiring planned or emergency acute care.
Verbatim wording from the response “We have considered the issues you raised in your report and we have worked with colleagues at Norfolk and Suffolk Mental Health Trust to develop a process for ensuring that patients under the care of mental health services who require acute care, either planned or as an emergency, have a clear pathway which includes agreed communication channels between clinicians, to expedite that care and reduce any potential for distress. Together we have developed a flow-chart to describe this process which is being used with immediate effect. I have attached a copy of this flow-chart for your information. We will monitor adherence to this new agreed process via the regular operational liaison meetings between our two trusts.” Source location 2015-0480-Response-by-James-Paget-University-Hospitals-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete development of a joint referral pathway enabling mental health inpatients to receive timely Emergency Department care through advance notification and agreed arrival times.
Verbatim wording from the response “I am writing to apologise that you did not receive a response to the Regulation 28 report following the death of Mr Christopher Higgins within the timeframe set out in your letter of the 24 December 2015. We have been working closely with Norfolk and Suffolk NHS Foundation Trust to develop a referral pathway which will ensure in the future that inpatients from our local mental health facility can access care and treatment in the Emergency Department in a timely manner that limits stress to the individual concerned.” Source location 2015-0480-Response-by-Queen-Elizabeth-Hospital-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop local protocols with acute-hospital colleagues for timely, least-distressing assessment of patients with mental health needs and incorporate them into policy.
Verbatim wording from the response “In addition to writing to the Trust, you have communicated with the local acute hospitals in Norfolk with the intention of raising to both services the consideration of how patients with mental health needs are cared for in a timely and least distressing way.” Source location 2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Trust
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Concerns raised 1
Delays in accepting transfer of suspected aortic dissection patients while awaiting CT imagery View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Kevin John Gilbert · Prevention of Future Deaths report
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Report summary
Kevin John Gilbert suffered an aortic root dissection on 29 January 2015 and died after cardiac arrest during transfer from William Harvey Hospital to St Thomas’ Hospital. The concerns included confusion about transfer protocols, delay in accepting him for transfer, and refusal to escalate the decision to a consultant; the report stated that his chances of survival would have been greater had the delay been avoided.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in accepting transfer of suspected aortic dissection patients while awaiting CT imagery
Wider context from the report “• Given that Mr Gilbert was presenting at William Harvey Hospital as an acute emergency requiring specialist surgery at a tertiary centre and that his diagnosis of suspicion made on presenting clinical symptoms by a Consultant in Accident and Emergency medicine which was confirmed by CT scan, it was not reasonable for ████████ to rely on his understanding of the procedure of accepting such patients and wait for the CT imagery before agreeing that he could be transferred .
” Source location Kevin John Gilbert · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clarify and reinforce to cardiothoracic registrars that aortic dissection referrals must be discussed immediately with the duty consultant, who decides transfer and any pre-transfer CT review.
Verbatim wording from the response “In January 2015, shortly after Mr Gilbert died, the referring consultant wrote to Mr Avlonitis, consultant cardiothoracic surgeon and raised concerns about the delay in transfer. Following receipt of the letter Mr Avlonitis wrote to all registrars in the Cardiothoracic Department to clarify the department’s process for accepting dissection referrals. He confirmed that all such referrals must be discussed immediately with the duty consultant and any decision to ask to review CT imagery before transfer could only be made by a consultant. The text of the email is shown below.” Source location Kevin-GILBERT-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend the open-door policy to ascending-aorta and arch dissections, enabling consultant-authorised immediate transfer with guaranteed theatre and critical-care capacity.
Verbatim wording from the response “I would also like to make the Coroner aware of a more recent change to the management of dissection referrals at the Trust. It has always been the case that there is an ‘open door’ policy for leaking abdominal aortic aneurysms, meaning they are accepted by the vascular surgical team for immediate transfer if clinically appropriate, with a guarantee that theatre and critical care capacity will be made available. This approach has now been extended to include dissections of the ascending aorta and arch such as suffered by Mr Gilbert. Therefore, from May 2016, any such referral to this Trust will be discussed immediately with the duty consultant cardiac surgeon (as outlined above), who will then be able to authorise immediate transfer if clinically indicated, with that same guarantee that theatre and critical care capacity will be made available.” Source location Kevin-GILBERT-Response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clarified consultant escalation and guaranteed immediate transfer arrangements are considered sufficient to prevent recurrence of confusion and delay.
Verbatim wording from the response “The Trust is absolutely committed to learning from incidents and about how care can be improved and delivered more effectively. I am confident that following the email, and the reinforcement of the message by consultant staff, that all junior staff are completely clear that dissection referrals must be reviewed immediately by the duty consultant and they understand that the transfer decision must be made by a consultant.” Source location Kevin-GILBERT-Response
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13 Apr 2015 Hayden Meirion NORTON · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 1
Unavailability of an emergency code protocol for calling an ambulance View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Dorset Healthcare University NHS Foundation Trust
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Hayden Meirion NORTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Hayden Meirion NORTON, a prisoner at HMP Dartmoor, became unwell with flank pain on 6 January 2014, suffered cardiac arrest, and died after resuscitation attempts. The report states that he died from a ruptured atherosclerotic abdominal aortic aneurysm. Concerns included a lack of recorded blood-pressure monitoring, no record that he had been informed about screening for aortic aneurysm, and a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code protocol.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of an emergency code protocol for calling an ambulance
Wider context from the report “The Deceased was medically assessed whilst an inmate of HMP Albany (now part of HMP Isle of Wight) on 28 September 2006 and known to have extensive and well documented history of high cholesterol, ischaemic heart disease with episodic angina, two previous myocardial infarctions, blood pressure 220/100. But after arrival at HMP Dartmoor on 15 March 2013,
(1) there was no record that his blood pressure was monitored; or
(2) that he had been informed of a screening test for aortic aneurysm.
He died on 6th January 2014 from a ruptured aortic aneurysm at HMP Dartmoor.
(3) There was a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code (unlike HMP Exeter) protocol.
There was insufficient evidence to say the above were causative of Mr NORTON’s death but there would have been an awareness of possible problems to come.
” Source location Hayden Meirion NORTON · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for establishing the prison’s emergency medical response code protocol rests with the Prison Service, specifically HMP Dartmoor’s Governor.
Verbatim wording from the response “3.3. The third of the concerns relates to the HMP Dartmoor service, at the time of this report it is not clear whether the prison have been asked to respond separately or whether the Trust is expected to do so on their behalf. The Trust is awaiting a response from HM Coroner’s office to determine this. For the purposes of this report the third recommendation has been left for HMP Dartmoor Governing Governor Bridie Oaks-Richards to respond to as this is a prison responsibility.” Source location 2015-0137-Response-by-Dorset-Health-Care-NHS-Trust
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Concerns raised 1
Delays and lack of clarity in control-room responses to medical emergencies View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Frankland Prison
Revise local contingency plans and reissue emergency instructions requiring timely ambulance calls and defining medical emergency response codes.
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Sharon Louise Suki Butcher · Prevention of Future Deaths report
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Report summary
Sharon Louise Suki Butcher died of natural causes, with the inquest recording ischaemic heart disease, coronary artery atheroma, diabetes mellitus and cirrhosis of the liver. The report raised concerns about a 10-minute delay in calling an ambulance after an emergency medical code was broadcast, failure to follow the prison’s local protocol, and recurring lack of clarity in responding to medical emergencies.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays and lack of clarity in control-room responses to medical emergencies
Wider context from the report “The PPO report highlights an issue relating to the delay in calling for an ambulance as soon as an emergency medical code was broadcast. There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed. There have been a series of similar failings in dealing with medical emergencies of HMP Frankland and HMP Durham with either staff using wrong or inappropriate codes, or there being delays in the control room and this recurring issue of lack of clarity in response to a medical emergency could well lead to a fatality in the future.
” Source location Sharon Louise Suki Butcher · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise local contingency plans and reissue emergency instructions requiring timely ambulance calls and defining medical emergency response codes.
Verbatim wording from the response “HMP Frankland revised their local contingency plans and re-issued instructions following the death of Ms. Sharon Butcher to ensure that all staff understood, that they must not delay in calling an ambulance in all cases where there are serious concerns about the health of an offender.” Source location 2015-0129-Response-by-NOMS
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16 Dec 2014 Mikey James Hornby · Prevention of Future Deaths report Manchester South
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Concerns raised 3
Failure to immediately admit children when meningitis is a realistic possibility View source Failure to immediately refer children with infected umbilical cords to hospital at first OOH attendance View source Failure to escalate seriously ill children to hospital during OOH assessment View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Mikey James Hornby · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mikey James Hornby was born on 31 March 2014 and died after being found lifeless at home on the morning after he attended an out-of-hours service with strange breathing. The report records neonatal E. coli sepsis and meningitis, with the conclusion of natural causes contributed to by neglect. Concerns included failures to refer him to hospital when he had an infected umbilical cord or possible serious illness, and the lack of access to immediate blood testing and antibiotics.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to immediately admit children when meningitis is a realistic possibility
Wider context from the report “1. On the first attendance at the OOH service, the attending staff having seen the infected umbilical cord, did not immediately send Mikey to the Hospital (as would have been the correct procedure according to the Consultant Lead Paediatrician who gave evidence to me.)
2. On the second attendance the doctor failed to appreciate the seriousness of the situation and at 10.45 at night sent the child home with a prescription for analgesia (which could not be filled until the following day in any event). The Consultant Paediatrician gave evidence to me “that there was a very high probability that he would have survived” had he been sent to the hospital at this time as he could and would have been administered an intra-venous anti-biotic.
3. If there is any realistic possibility of the condition being meningitis, the child should have been immediately admitted to the hospital .
4. The GP covering the surgery that night indicated that they do not have the facility to take a simple blood test. If this is the case, then they should utilise the adjacent facilities at the Emergency Department of the hospital.
” Source location Mikey James Hornby · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to immediately refer children with infected umbilical cords to hospital at first OOH attendance
Wider context from the report “1. On the first attendance at the OOH service, the attending staff having seen the infected umbilical cord, did not immediately send Mikey to the Hospital (as would have been the correct procedure according to the Consultant Lead Paediatrician who gave evidence to me.)
2. On the second attendance the doctor failed to appreciate the seriousness of the situation and at 10.45 at night sent the child home with a prescription for analgesia (which could not be filled until the following day in any event). The Consultant Paediatrician gave evidence to me “that there was a very high probability that he would have survived” had he been sent to the hospital at this time as he could and would have been administered an intra-venous anti-biotic.
3. If there is any realistic possibility of the condition being meningitis, the child should have been immediately admitted to the hospital.
4. The GP covering the surgery that night indicated that they do not have the facility to take a simple blood test. If this is the case, then they should utilise the adjacent facilities at the Emergency Department of the hospital.
” Source location Mikey James Hornby · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to escalate seriously ill children to hospital during OOH assessment
Wider context from the report “1. On the first attendance at the OOH service, the attending staff having seen the infected umbilical cord, did not immediately send Mikey to the Hospital (as would have been the correct procedure according to the Consultant Lead Paediatrician who gave evidence to me.)
2. On the second attendance the doctor failed to appreciate the seriousness of the situation and at 10.45 at night sent the child home with a prescription for analgesia (which could not be filled until the following day in any event). The Consultant Paediatrician gave evidence to me “that there was a very high probability that he would have survived” had he been sent to the hospital at this time as he could and would have been administered an intra-venous anti-biotic.
3. If there is any realistic possibility of the condition being meningitis, the child should have been immediately admitted to the hospital.
4. The GP covering the surgery that night indicated that they do not have the facility to take a simple blood test. If this is the case, then they should utilise the adjacent facilities at the Emergency Department of the hospital.
” Source location Mikey James Hornby · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement NICE feverish-illness guidance in the out-of-hours service using PEWS and assessment templates.
Verbatim wording from the response “In 2013, the Trust implemented national NICE guidance dated May 2013 entitled “Feverish illness in children: Assessment and initial management in children younger than 5 years” which is based on validated algorithms. A copy of a link to the NICE guidance is enclosed, for your ease of reference: http://www.nice.org.uk/cg160/chapter/recommendations.” Source location 2014-0536-Response-by-Bridgewater-Community-Healthcare-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quarterly clinical audits of practitioners’ records and provide supervision and competency action plans where practice falls short.
Verbatim wording from the response “Ongoing checks on the quality of the services we provide are made via quarterly clinical audit reviews, where a sample of clinical and medical records from each practitioner are reviewed by the clinical director enabling best practice to be recognised and shared with colleagues. Where best practice is not followed a period of supervision and formal support with competency improvement action plans is implemented.” Source location 2014-0536-Response-by-Bridgewater-Community-Healthcare-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide training on managing severely ill children for out-of-hours GPs alongside mandatory and statutory training.
Verbatim wording from the response “Annual appraisals take place with all staff. Learning from incidents in service allows GPs to review their training needs so that alongside maintaining their annual Mandatory and Statutory Training, particular development needs can be met. For GPs in the Out of Hours Service, their Bridgewater-specific training will often run alongside the continuing professional development they undertake as part of their practice. In ████████ case, he has undertaken training on management of the severely ill child to support his general practice role.” Source location 2014-0536-Response-by-Bridgewater-Community-Healthcare-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The clinical data produced a PEWS score of 0–2, which did not indicate that further action or hospital referral was required.
Verbatim wording from the response “The Trust is fully compliant with this guideline. The Trust uses the Paediatric Early Warning Score (PEWS) system in the GP Out of Hours service as a way of ensuring that the steps recommended in the NICE guidance are considered (please see attachment one). Although the score sheet was not available during ████████ examination of Baby Mikey, running the score from the clinical data of the consultation showed the score is 0-2 which did not indicate further action was required.” Source location 2014-0536-Response-by-Bridgewater-Community-Healthcare-NHS-Trust
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7 Nov 2014 Colin John Ireland · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 4
Lack of an agreed protocol for seeking approval for emergency release to hospital View source Failure of the on-call system to provide reliable telephone access to the responsible approval function View source Failure to prioritise preservation of life over security concerns in emergency medical decisions View source
Failure to appropriately act on clinical judgement of a potentially life-threatening condition View source See 1 more concern
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Colin John Ireland · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Colin John Ireland, a diabetic prisoner at HMP Wakefield, fell and fractured his left hip during exercise in icy weather on 11 February 2012. After surgery and discharge to the prison healthcare centre, he collapsed and died on 21 February 2012; the inquest recorded pulmonary thromboembolism and deep venous thrombosis. Concerns included delay in transferring him to hospital, difficulties with the high-security prison approval system, and the absence of an agreed protocol and training for Governors responding to medical emergencies.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of an agreed protocol for seeking approval for emergency release to hospital
Wider context from the report “3. That the Governor Grade Officers who gave evidence had differing views as to the action to be taken, in particular in relation to seeking approval from the High Security Prisons Group regarding release to hospital in such circumstances . I consider that there should be an agreed protocol for this and that all on-duty Governors should receive appropriate training regarding responding to medical emergencies of all types to ensure a speedy release to hospital when necessary, obviously without prejudicing appropriate security issues. Although the Duty Governor claimed to acknowledge that preservation of life was paramount, he appeared to be more motivated by Mr Ireland’s notoriety than to the serious issues of his condition which created an unacceptable delay.
” Source location Colin John Ireland · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the on-call system to provide reliable telephone access to the responsible approval function
Wider context from the report “2. That the same Governor Grade Officer had difficulty in contacting by telephone the on-call [████████] for the High Security Prison Group to seek permission for Mr Ireland to be sent to hospital. Apparently, [████████] was not responding to her calls . I request that the Director of the High Security Prison Group specifically address this issue in response to this report. Fortunately, the Governor had through his own dealings with [████████] who was then the Director of High Security Prisons, his contact details who was then able to give the relevant permission. I understand that this was an unofficial approach which I do not criticise but would point out that other Duty Governors may not have had access to [████████] number, which would have lengthened the delay . It occurs to me that the on-call system is flawed and should be reviewed.
” Source location Colin John Ireland · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to prioritise preservation of life over security concerns in emergency medical decisions
Wider context from the report “3. That the Governor Grade Officers who gave evidence had differing views as to the action to be taken, in particular in relation to seeking approval from the High Security Prisons Group regarding release to hospital in such circumstances. I consider that there should be an agreed protocol for this and that all on-duty Governors should receive appropriate training regarding responding to medical emergencies of all types to ensure a speedy release to hospital when necessary, obviously without prejudicing appropriate security issues. Although the Duty Governor claimed to acknowledge that preservation of life was paramount, he appeared to be more motivated by Mr Ireland’s notoriety than to the serious issues of his condition which created an unacceptable delay .
” Source location Colin John Ireland · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to appropriately act on clinical judgement of a potentially life-threatening condition
Wider context from the report “1. That a Governor Grade Officer who had sole responsibility for the running of the Prison challenged the clinical judgement and decisions of both an experienced nurse and an on-call GP who believed that Mr Ireland had fractured his hip and that this was a potentially life-threatening condition and that he should be sent to hospital as an emergency .
” Source location Colin John Ireland · Prevention of Future Deaths report
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5 Nov 2014 William DAVIES · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to request an ambulance promptly after a level one call View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Care UK Limited
Deliver and disseminate an emergency healthcare response publicity campaign to operational, non-operational and healthcare staff.
View source
Care UK Limited
Review emergency care arrangements, including staff training and standardisation of emergency bags.
View source
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William DAVIES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Davies was found unresponsive in his cell at HMP Pentonville and died from natural causes, identified as coronary artery atherosclerosis. Concerns were raised about unclear procedures and delays in requesting an ambulance after a life-threatening call, as well as uncertainty among prison healthcare staff about responsibilities and verification of death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to request an ambulance promptly after a level one call
Wider context from the report “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer.
1. I have been told in other inquests (and delay in HMP Pentonville ensuring ambulance attendance has been a feature since the first prison death inquest I heard in Inner North London, on 30 September 2013 ) that prison comms should call an ambulance as soon as they have been notified of a level one .
However, the prison duty governor on the day of Mr Davies’ death, ████████ said that when he arrived two or three minutes after the prison officer who found Mr Davies had contacted comms, no ambulance had been called . ████████ told me that he did not know why this was, though he was duty governor that day and the most senior person from the prison in court.
2. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she had learnt that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either.
” Source location William DAVIES · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver and disseminate an emergency healthcare response publicity campaign to operational, non-operational and healthcare staff.
Verbatim wording from the response “• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.” Source location Response from Care UK
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review emergency care arrangements, including staff training and standardisation of emergency bags.
Verbatim wording from the response “• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.” Source location Response from Care UK
Open published response
23 Jun 2014 JOAN DOROTHY RICHARDSON · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to identify urgent presentations requiring immediate hospital referral View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
JOAN DOROTHY RICHARDSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joan Dorothy Richardson became seriously unwell with rapid swelling, bruising and discolouration of her arm. After her GP surgery was closed for staff training on 21 November 2013, she was seen the following day, suffered a cardiac arrest in hospital, and died; the cause of death was streptococcal toxic shock syndrome. The concerns were that emergency medical cover and clear arrangements for patients should be available when GP surgeries close for training, and that the delay of almost 24 hours contributed to the outcome.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify urgent presentations requiring immediate hospital referral
Wider context from the report “(5) No criticism is made that a precise diagnosis was not made. Nevertheless had Ms Richardson been seen on the 21st November 2013 it would have been obvious that she was extremely unwell and that her presentation was urgent and that time was of the essence and that she should have been referred to hospital immediately .
” Source location JOAN DOROTHY RICHARDSON · Prevention of Future Deaths report
Open source report
25 Feb 2014 Stephen John PALMER · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Failure to arrange an emergency theatre View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Stephen John PALMER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen John Palmer’s death was the subject of an inquest, but the supplied text does not describe the circumstances of the death. Principal concerns included delays in assessment and review, inappropriate transfer to an Acute Medical Unit, failure to recognise deterioration, suboptimal clinical management, inadequate preparation and arrangements for urgent surgery, and failure of the CT scanning service.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to arrange an emergency theatre
Wider context from the report “(9) Failure to arrange an emergency theatre for him (CEPD).
” Source location Stephen John PALMER · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.